Federal Legislative Issues

Federal Legislative Updates

First enacted in 1976, the Indian Healthcare Improvement Act (IHCIA) is the legislative embodiment of the federal trust and treaty responsibilities to American Indian and Alaska Native people for healthcare. IHCIA was permanently enacted in 2010 as part of the Patient Protection and Affordable Care Act (ACA), though it is unrelated to the underlying healthcare reform legislation. It was tacked onto to the end of the law at Section 10221.

The IHCIA is the statutory authority for Urban Indian Health Organizations and provides a wealth of new resources, opportunities, and protections for Tribal and Urban Indian health programs, families, providers and patients. The law also provides the foundational authority for the Indian health Service to be reimbursed by Medicare, Medicaid, and third party insurers; to make grants to Indian Tribes; and to run programs designed to address specific, critical health concerns for American Indians and Alaska Natives such as substance abuse, diabetes, and suicide.

Tribes and Indian health leaders fought for over a decade to see this legislation move, and when ACA was moving through Congress in 2010, it was decided the ACA would be a good vehicle to get it enacted, not because it was related to healthcare reform. The permanent reauthorization of the IHCIA included long over due updates which modernized the Indian health care system and began a new chapter in the delivery of quality health care to American Indians and Alaska Natives.

Indian-Specific Protective Provisions in the ACA

In addition, there are Indian-specific provisions in the ACA, other than the IHCIA, that provide important protections and funding opportunities for the Indian Health Service/Tribal/ and Urban Indian health (I/T/U) system:

–Section 2901 which states that any I/T/U should remain the payer of last resort the payer of last resort for services provided by such notwithstanding any Federal, State, or local law to the contrary.

–Section 9021 ensures that any health benefits provided by a tribe to its members are not included as taxable income.

–Medicaid Benefits for AI/ANs. Under current law, the federal government reimburses States for 100 percent of the cost of providing Medicaid services to AI/ANs at IHS and Tribal facilities. Any plan to change the manner in which State Medicaid costs are reimbursed by the federal government must include a carve out for services provided to AI/ANs at I/T/U facilities so that the federal government’s trust responsibility is not shifted to the States.

The Patient Freedom Act and the IHCIA

See this document for information on The Patient Freedom Act of 2017, which was introduced on January 23, 2017 by Senators Cassidy (LA-R) and Collins (ME-R) to partially replace the Affordable Care Act (ACA) and its impact on Urban Indian Health Providers (UIHP).

The Affordable Care Actcannot be repealed without a viable replacement that ensures coverage, affordability, and access to care for all Californians.

California’s most vulnerable and underserved communities have the most to lose if healthcare coverage programs are rolled back or eliminated and there must be replacement programs ready to fill the void. Community health centers are a local, innovative, cost-effective, and bi-partisan solution that ensures access to excellent healthcare for everyone.

As of February 1st 2017, the United States Senate and House of Representatives have already taken the first procedural steps to begin the budget reconciliation process, which will be used to repeal the financial elements of the Affordable Care Act. President “Why doesn’t he show his birth certificate” “Nobody builds walls better than me” “I have so many websites” “Somebody’s doing the raping” Donald “The American dream is dead” Trump has issued an executive order that outlines his intent to repeal.

Successes

Due to the increased access and affordability of health insurance through the ACA, communities are healthier, with the uninsured rate in California falling from 17.2% in 2013 to a historic low of 8.6% in 2015 (CHCF), whereas for community clinics, it dropped from 35% in 2012 to 24% in 2015.

Covered California, the state’s health insurance marketplace, built a competitive marketplace that puts 1.2 million consumers in the driver’s seat, giving them the power to select plans and providers. In January 2017 alone, Covered California reported that 60 percent of consumers receiving tax credits can get a Bronze plan for less than $10 per month. Consumers who are changing their plan during their renewal are saving on average $38 per month.

Repercussions of Repeal

An estimated 209,000 California jobs (135,000 in healthcare) would be eliminated, further damaging California’s GDP, which would take a $20 billion hit, and the state would lose 1.5 billion in tax revenue. These losses would affect most severely counties with the highest Medi-Cal enrollment, like those in the central valley and rural areas (UC Berkley Labor Center).

5 million Californians will be uninsured. Of which, are 1.2 million patients who are served by community health centers (Medicaid and Covered CA).

If there is repeal, we cannot delay the replacement. It invites unnecessary stress and chaos for communities who already struggle to make it through the day and put food on the table.

A Viable Alternative Must Include:

Coverage: Broad coverage programs that provide access to care for all Californians. We cannot abandon the five million Californians who received coverage through the Medi- Cal expansion and Covered California.

Affordability: The coverage programs have to be affordable. For a family of four who earns $30,000 a year, seemingly insignificant premiums can derail their coverage hopes (Medicaid expansion family income for family of four).

Access: Coverage doesn’t guarantee access to care. As a nation, we need to remain committed to strengthening our safety-net healthcare infrastructure and training healthcare professionals who reflect the communities they serve.

Health Centers are a Bipartisan Solution

Presidential administrations on both sides of the political aisle have been architects of expanding health centers for the past 16 years because they know health centers save both lives and tax dollars. Health centers generate $24 billion in savings to the health care system every year by efficiently managing and treating chronic disease, even among the most economically challenged populations.

Investing in Expanding Health Centers is Critical

Some 62 million Americans lack access to primary care because of a variety of factors, including long distances from health care facilities, affordability of care, and a shortage of available doctors and other providers. People from all walks of life are affected. Nearly half (42%) are low-income and 28% live in rural communities. Surprisingly, the vast majority of the people without access to primary care actually have insurance, but just have few or no options in terms of where they can get care.

Community health centers will be crucial to providing essential care to people who need access to health care services in the event of a disruption to the insurance market that leave people without access to other provider options. They have been solutions to public health crises in the past and maintaining funding so that they can continue to provide those solutions is absolutely necessary.

Policy Briefs

Medicaid Block Grants

Block grants, the proposed alternative funding method to the current Medicaid cost structure, would reduce the contributions by the federal government currently made that go towards covering the cost of states’ Medicaid programs. Moving forward, the federal government would be responsible instead for only a flat dollar amount of the state’s Medicaid costs, as opposed to a fixed percentage, which currently allows for much greater flexibility in funding more expansive treatment options to meet the needs of diverse and underserved communities.

Under a block grant system, states would bear a much greater burden of the cost it takes to serve their most needful populations. Block grants may also include narrower parameters of eligibility for receiving care, leaving many unique needs unmet. There is a strong possibility that this change will also result in the cutting of coverage programs and lead to the rationing of care, resulting in an overall depreciation of patient health.

Tax Credits and Health Savings Accounts

Tax credits and Health Savings Accounts have also been discussed as potential alternatives. But the reality of these proposed solutions is that they ignore the fact that many families cannot pay the up-front cost of health care premiums to begin with, making the idea of budgeting for a savings account to cover the cost of future premiums or receiving tax credit long after paying for premiums months earlier wholly unfeasible. These solutions ignore low-income families that do not have the extra money to set aside in the present or the financial security to wait months for minimal reimbursement. We need solutions that serve everyone.

On April 14, 2015, the U.S. Senate passed a two (2) year renewal for the Special Diabetes Program for Indians (SDPI). The renewal was contained in a larger bill called The Medicare Access and CHIP Reauthorization Act of 2015 (HR 2). CCUIH is grateful to the National Indian Health Board for the work that they continue to do to make this program sustainable and effective for the long-term.

SDPI is one of many programs in this legislation. Other provisions included a 2-year authorization of the Children Health Insurance Program (CHIP) and a permanent adjustment of the Medicare physician payment formula. You can read a summary of the legislation here.

SDPI provides critical programs that are helping our Tribal communities address complications and burdens of Type 2 diabetes. The newly-passed legislation funds SDPI at $150 million per year, which is the same as the current level. This program will now expire on September 30, 2017.

Congress established the Special Diabetes Program for Indians (SDPI) in 1997 as part of the Balanced Budget Act to address the growing epidemic of diabetes in American Indian and Alaska Native communities. SDPI currently provides grants for 404 programs in 34 states – including California. At a rate of 2.8 times the national average, American Indians and Alaska Natives have the highest prevalence of diabetes. In some AIAN communities, over 50% of adults have been diagnosed with type 2 diabetes. SDPI is changing troubling statistics like this, with marked improvements in average blood sugar levels, reductions in the incidence of cardiovascular disease, prevention and weight management programs for our youth, and a significant increase in the promotion of healthy lifestyle behaviors. This success is due to the nature of this grant program to allow communities to design and implement diabetes interventions that address locally identified community priorities.

April 16, 2015 Congressman Valadao (R-CA) introduced H.R. 1842 The Indian Health Service Health Professions Tax Fairness Act of 2015, whichamends the tax code to provide healthcare professionals who receive student loan repayments from the Indian Health Service the same tax free status enjoyed by the National Health Service Corps. Senator Tom Udall (D-NM) sponsored S. 536 with the same title in February.

Currently, there are over 1,550 health professional vacancies in the Indian Health Service. Making IHS loan repayment tax exempt would free up $5.71 million, funding an additional 115 health professionals.Each Indian Health Service medical professional in the program will bring in significant added revenue through 3rd party billings.

H.R. 1842 and S. 536 would help recruit and retain health professionals to serve in underserved American Indian communities throughout the nation. Our Urban Indian communities in California could greatly benefit from this legislation, particularly those in the Fresno American Indian Health Projects and the Bakersfield American Indian Health Project service areas.

This bill is bipartisan with support from Republicans and Democrats in the House, Senate, and language from the Executive Branch.

On Wednesday, January 14, Congressman Don Young (R-AK) introduced H.R. 395 which would provide for Advance Appropriations for the Indian Health Service (IHS). Tribes and Urban Indian health organizations have been supporting this change in the way IHS is funded in order to achieve better stability in how our health care is funded.

The Indian Health Service Advance Appropriations Act of 2015 would allow the IHS to receive advance appropriations, which are appropriations available one or more years beyond the year for which the appropriations act is passed. This bill would amend the Indian Health Care Improvement Act to authorize advance appropriations for IHS by providing 2-fiscal-year budget authority, meaning that IHS, Tribal and Urban (I/T/U) facilities would know their funding levels one year in advance, although the funds would not be drawn down until the year in which it was spent.

Since FY 1998, appropriated funds for medical services and facilities through IHS have not been provided before the commencement of the new fiscal year, causing Indian health providers great challenges in planning and managing care for American Indians. Although the IHS budget has increased by a historic 29% since 2008, this equates to an average of 7.25% per year, barely enough to cover medical and non-medical inflation and the cost of contract health care for our growing population. Both serious budgetary increases and changes to resources supporting this health care system are necessary if we are going to effectively address the growing gap in health disparities, which has resulted in early death, and preventable, expensive chronic care costs for AI/ANs of all ages. The lateness in enacting a final budget ranges from five days (FY 2002) to 197 days (FY 2011), making quality budget planning almost impossible.

Health care services in particular require consistent funding to be effective. In FY 2010, the Veterans Administration (VA) medical care programs achieved advance appropriations. The fact that Congress has implemented advance appropriations for the VA medical programs demonstrates the importance of advance appropriations for direct health service agencies. Just as the veterans groups were alarmed at the impact of delayed funding upon the provision of health care to veterans and the ability of VA to properly plan and manage its resources, I/T/U facilities have those concerns about the IHS health system. If IHS funding was on an advance appropriations cycle, I/T/U facilities would know the funding a year earlier and their health care services would not be stymied by continuing resolutions. This would lead to greater outcomes for patients in I/T/U programs. For example, hospital administrators would have the ability to continue treating patients without wondering if they had to de-fund facilities or programs. Additionally, IHS administrators would not waste valuable resources in an agency funded at only 56 percent of need by re-allocating the budget each time Congress passed a continuing resolution. Indian health providers would know in advance how many physicians and nurses they could hire without wondering if funding for positions would be available from month to month.

On June 4, 2015 Senators Tom Udall (D-N.M.) and Jon Tester (D-Mont.) introduced legislation to exempt the Indian Health Service, Bureau of Indian Affairs, and other Indian programs from the mandatory sequestration expected for the FY-2016 fiscal year.

“Across-the-board budget cuts presented a major setback for Indian Country, forcing cuts to vital programs that New Mexico tribal communities depend on,” Udall said. “We have a trust responsibility to uphold to tribes, and I’m pleased to work with Senator Tester on this legislation to ensure that important health care, education, public safety and housing programs that support economic growth in Indian Country won’t be subject to future disastrous sequestration cuts.”

“Congress must uphold its trust responsibilities rather than balancing the budget on the backs of folks in Indian Country,” Tester said. “This bill prevents further damaging cuts to health care, education, public safety, and housing for Native American families.”

The negative impacts of sequestration on Indian programs include a $220 million cut to Indian Health Services. To learn more about the impact of sequestration on Indian Country visit NCAI.

Children’s wellbeing is vital to future of Native communities, 31.6% percent of Natives are under the age of 18, compared with 24% of the total population (2010 Census). During June of 2015, two pieces of legislation advanced in Congress which are designed to help Native children with the complex issues that they face.

Some of the issues that Native children and youth face include poverty, suicide, mental health disorders, alcohol use disorders, and gang involvement. Natives have the highest rate of poverty compared to any other racial group in the nation. In 2009, the poverty rate of Native peoples was 27.3%, almost twice the national poverty rate of 14.2 (USDC, 2009). Suicide is the leading cause of death for Native males ages 10-14, and one-fifth of Native young adults ages 15 to 24 died by suicide (CDC, 2010.) A 2006 study found that, compared to other groups, Native youth have more serious problems with mental health disorders. Specifically, Native youth have higher rates of anxiety, substance abuse, and depression. (Olson, L.M. & Wahab, S.; 2006 American Indians and Suicide: A Neglected Area of Research). Alcohol-use disorders are more likely among American Indian youths than other racial groups; 8.5% of all Native youth were struggling with an alcohol use disorder compared to 5.8% of the general use population in 2007. (SAMHSA). Native youth are more affected by gang involvement than any other racial population; 15% of AI/AN youth are involved with gangs compared to 8% of Latino youth and 6% of African American youth nationally. (National Council on Crime and Delinquency, 2009).

The Alyce Spotted Bear and Walter Soboleff Commission on Native Children Act, S. 246, would create a commission on Native Children that would work to identify the complex challenges faced by Native children by conducting an intensive study on these issues. The bill was sponsored by Senators Heidi Heitkamp (D-ND) and Lisa Murkowski (R-AK). It passed the U.S. Senate unanimously on June 1, 2015.

Alyce Spotted Bear and Walter Soboleff Commission on Native Children Act establishes the Alyce Spotted Bear and Walter Soboleff Commission on Native Children in the Office of Tribal Justice of the Department of Justice (DOJ). Th bill requires the Commission to conduct a comprehensive study of federal, state, local, and tribal programs that serve Native children, including an evaluation of: the impact of concurrent jurisdiction on child welfare systems; barriers Indian tribes and Native Hawaiians face in applying, reporting on, and using existing public and private grant resources; obstacles to nongovernmental financial support for programs benefitting Native children; issues relating to the validity and statistical significance of data on Native children; barriers to the development of sustainable, multidisciplinary programs designed to assist high-risk Native children and their families, as well as any examples of successful program models and use of best practices; and barriers to interagency coordination on programs benefitting Native children.

The results of the study will inform plans and goals for federal policy relating to Native children in the short-, mid-, and long-term, which shall be informed by the development of accurate child well-being measures; recommend modifications and improvements to programs that serve Native children at the federal, state, and tribal level that would integrate the cultural strengths of Native communities and improve those programs; recommend improvements to the collection of data regarding Native children and the programs that serve them; and identify models of successful federal, state, and tribal programs in the areas studied by the Commission. Requires the Commission to submit a report to the President, Congress, and the White House Council on Native American Affairs on its findings, conclusions, and recommendations for appropriate legislative and administrative action.

Native American Children’s Safety Act (H.R. 1168 and S.184)

Native American Children’s Safety Act amends the Indian Child Protection and Family Violence Prevention Act (Act) to prohibit any foster care placement over which an Indian tribe has exclusive jurisdiction from being ordered until the tribal social services agency:

(1) completes an investigation of the character of each covered individual who resides in the household or is employed at the institution in which the foster care placement will be made, and
(2) concludes that each of those individuals meets the standards of character the tribe is required to establish.

This can be a violation of tribal sovereignty and create circumstances that maintain the status quo of sending too many Native children to non-Native foster homes.

Health Happens with Prevention

The California Consortium for Urban Indian Health is pleased to work with The California Endowment to raise public awareness about the importance of prevention through the “Health Happens with Prevention” campaign.

About CCUIH

The California Consortium for Urban Indian Health (CCUIH) is an alliance of direct service Urban Indian health organizations that supports health promotion and access for American Indians living in cities throughout California.